Neuroprotective Benefit of Renin-Angiotensin System Blocking Agents in Carotid Artery Surgery

Abstract

Renin-angiotensin system blocking (RASB) agents such as angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are considered first-line antihypertensive agents. However, their role in the perioperative period of carotid artery interventions is unclear. We examined the relationship between the use of RASB agents for patients undergoing carotid endarterectomy (CEA), transfemoral carotid artery stenting (CAS), and transcervical carotid artery revascularization (TCAR). The Vascular Quality Initiative database was queried for all patients who had undergone CEA, TCAR, and CAS. The baseline and procedural characteristics and postoperative outcomes were compared between the RASB agent users and nonusers. The primary outcome was postoperative neurologic events (stroke and transient ischemic attack). The secondary outcomes included postoperative mortality, cardiac events, and postoperative complications. Multivariate logistic regression was used to determine the independent predictors of postoperative neurologic events. More than 150,000 patients were analyzed, including13,666 patients who had undergone TCAR, 13,811 who had undergone CAS, and 125,429 who had undergone CEA (Fig). On univariate analysis, RASB agent use was associated with lower postoperative neurologic events after CEA (1.7% vs 2.0%; P = .001). No difference was detected in the TCAR (2.0% vs 2.4%; P = .162) and CAS (3.4% vs 3.2%; P = .234) cohorts. However, RASB agent use was associated with lower mortality after CAS (1.2% vs 1.7%; P = .001). RASB agent use did not influence the overall rates of cardiac events, including myocardial infarction, dysrhythmia, and congestive heart failure for all intervention types or mortality in the CEA and TCAR groups. On multivariable analysis, RASB agent use was independently and significantly associated with lower rates of postoperative neurologic events for the patients who had undergone CEA (odds ratio [OR], 0.819; 95% confidence interval [CI], 0.747-0.898; P = .01) or TCAR (OR, 0.869; 95% CI, 0.768-0.984; P = .026), but not after CAS (OR, 0.967; 95% CI, 0.884-1.057; P = .461; Table). RASB agent use was associated with decreased neurologic events in the patients who had undergone CEA or TCAR but not for those who had undergone CAS. Because all carotid artery interventions warrant absolute minimization of perioperative complications to be efficacious, the neuroprotective effect associated with RASB agent use during CEA and TCAR warrants further examination.TableMultivariable analysis resultsOR95% CI1.1471.083-1.2151.0621.030-1.0951.0301.009-1.0521.0260.978-1.0761.0191.003-1.0340.9990.964-1.0360.8950.790-1.0150.8880.782-1.0080.8190.747-0.8980.7690.698-38471.2301.020-1.4831.0551.003-1.1081.0471.002-1.0940.9620.844-1.0961.2080.914-1.5950.9890.911-1.0731.1540.752-1.7731.0260.813-1.2950.8690.768-0.9840.8630.812-0.916CI, Confidence interval; OR, odds ratio.Boldface values represent statistical significance. Open table in a new tab